International Health Care Management Part 2b

1. International Health Care Management Part 2b Steffen Fleßa Institute of Health Care Management University of Greifswald

2. Epidemiology of Non-Infectious Diseases 2 Demand for Health Services 2.1 Determinants of Demand: Overview 2.2 Demographic and Epidemiologic Transition 2.3 Epidemiology of Infectious Diseases 2.4 Epidemiology of Non-Infectious Diseases 2.4.1 Overview 2.4.2 Example: Diabetes Mellitus Type II 2.4.3 Example: Cervix Uteri Carcinoma 2.5 Risk Factors 2.6 Filter Between Need and Demand

3. 2.4.1 Overview • Problem: • Multi-Cause-Multi-Effect Model • Not yet a general concept • Problems of Distinction: • Infectious diseases may become chronic • Infections have a certain role in chronic-degenerative diseases • i.e. Cervix Carcinoma, Gastric Cancer, Liver Cancer • i.e. Caries

4. Relevance (WHO 2007)

5. Development (WHO 2007)

6. Mortality Risk: absolute Mortality (per 100.000 pop., age adjusted)

7. Fatalities Due to Cardio-Vascular Diseases

8. Mortality in Germany • Cardio-Vascular Diseases • 450.000 fatalities annually (49 % of total fatalities in Germany) • Cancer • 210.000 fatalities annually (23 % of total fatalities in Germany) • Stroke (ICD 430-438) • 110.000 fatalities annually (estimated; 12 % of total fatalities in Germany) • Consequence: • The absolute risk of dying from a chronic disease in developing countries is higher than it is in Germany • The relative risk (in comparison to other diseases) is lower in developing countries

9. Cardio-Vascular Diseases • Type: • Coronary Insufficiency: • Caused by an absolute or partial lack of blood flow to the coronary arteries; acute coronary insufficiency leads to angina pectoris (attack like pain in the area of the heart with a characteristic feeling of constriction) • Myocardial Infarction (Heart Attack): • Partial death of cells in the heart muscle caused by an acute lack of oxygen (ischemia) • 85.000 fatalities annually

10. Development of Casualties • 1845: 0,05 % of death cases due to cardio-vascular diseases • High increase in phase three and four of the epidemiologic transition • Decline since 1990 • Less in women than in men • USA: less in Caucasian than in Afro-American population • Higher survival rate since 1990 • Lower rates of second and third time infarcts since 1990

11. Congenital Heart Disease • Congenital: at birth • Genetic disorder • Strongly: Arabic countries • Reason? • http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2765422/

12. Genetic Disposition of Heart Diseases: Relationship in blood http://nature-sucks.blogspot.de/2012_01_01_archive.html

13. http://www.bqdoha.com/2013/09/gulf-explained-40-maps-part-2

14. Cancer • Collective name for more than 100 diseases that can occur in any part of the body. • Rapid development of abnormal cells that grow beyond their normal limits • Cancer cells destroy adjacent tissue and spread to other organs (metastases) • Metastases are the main cause of death in cancer

15. Epidemiology • Mortality: • Main cause of death worldwide • 7.6 Million death cases annually worldwide (13 % of total fatalities), • Forms of cancer with high mortality: • Lung cancer (1.3 Mio.) • Gastric cancer (1 Mio.) • Liver cancer (662,000 ) • Colon cancer (655,000) • Breast cancer (502,000) • Spread: 70 % of worldwide death cases due to cancer in developing countries • Estimations: 11.3 Mio. death cases due to cancer worldwide in 2030

16. Examples • Note: extremely varying spatial distribution • Genetic disposition • i.e. low risk of melanoma in Asians and Africans • Habitat / Exposition • i.e. skin cancer in Australia • Behavior • i.e. liver cancer  alcohol, mold • i.e. lung cancer  smoking

23. Cause • Basic Problems: • Manifestation long time after exposition • Stochastic relation of exposition and occurrence of disease • Temporal or spatial association of exposition and disease is challenging • Trigger: • Ultraviolet or radioactive radiation • Chemicals, i.e. asbestos, smoke • Problem of “Indoor Smoke” in developing countries • Biological triggers, i.e. • Viruses • Hepatitis B Virus and Liver cancer • Human Papilloma Virus (HPV) and cervical carcinoma • Bacteria • Helicobacter pylori and gastric cancer • Parasites • Schistosomiasis and bladder cancer • Fungi • i.e. Aspergillus fungi and liver cancer

24. 2.4.2 Example: Diabetes Mellitus Type II • 2010 (WHO-Statics): • 382 million diabetics worldwide • 90 % T2DM • 80 % of diabetics live in middle or low income countries • 2035: (estimates of the International Diabetes Federation) • 471 million cases • Seventh leading cause of death worldwide

25. T2DM • Type-2-Diabetes • Chronic Degenerative Disease • Insulin resistance • Inadequate insulin secretion of β-cells, spectrum reaches from predominant insulin resistance accompanied by a relative lack of insulin to a predominant defect of insulin secretion accompanied by insulin resistance • Treatment • Diet • Oral therapy • Insulin replacement therapy

26. Distribution Source: Kaitlin et al. 2012

27. Complications • Micro Vascular Complications • Retinopathy (retinal diseases) • Nephropathy (kidney disease, dialysis) • Macro Vascular Complications • Heart Attack • Stroke • Neuropathy (neurological diseases) • Diabetic Foot Ulcers (circulatory disorders of extremities)

28. Diabetes in Cambodia • WHO STEPS (2010): Population 25-64 years: • 2.9 % countrywide • 5.6% urban • 2.4% rural • exposure to NCD risk factors: 80% had at least one risk factor • Cambodia epidemiologic survey • Siem Riep province: 4.8 % • Kampong Cham province: 11.4 % • Source: WHO 2011

29. Model

30. Model

31. Model

32. Model

33. Diagnosed and Undiagnosed Cases

34. Diagnosed Cases With and Without Complications

35. Therapy of Diagnosed Cases

36. Budget Impact

37. Impact of OAD Coverage (current = 12.5 %) Incremental Cost per Life Saved: 800 US$ (r=5%)

38. Impact of Insulin Coverage (basic = 12.5 %) Incremental Cost per Life Saved: 3392US$ (r=5%)

39. 2.4.3 Example: Cervix Uteri Carcinoma • Agent: Humane PapillomaVirus (HPV) • Numerous subtypes, few of them carcinogenic • Incidence: 500,000 new cases and 270,000 fatalities worldwide p.a. • Transmission: primarily through sexual intercourse

40. http://eco.iarc.fr/EUCAN/CancerOne.aspx?Cancer=25&Gender=2

41. Cervix Uteri Carcinoma • Prevention: • Vaccination (three vaccines prior to first sexual intercourse) • Screening • VIA: visual inspection with acetic acid • Pap smear • Genetic testing

42. Screening Source: WHO 2006

43. Cervix Uteri Carcinoma • Treatment: • pre-invasive: cryotherapy, “cold coagulation” • invasive: surgery, radiotherapy

44. Model

45. Parameter

46. Case Development Cambodia

47. Incremental Cost Effectiveness Ratio (ICER) of Treatment

48. Cost of Treatment

49. Screening (w/o Treatment)

50. Vaccination (w/o Treatment)